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Authorization and Consent For Microcurrent Facial Toning (Canada) Mobile App

The Authorization and Consent For Microcurrent Facial Toning (Canada) is a form template for patient's consent and authorization prior to microcurrent facial toning procedures. It covers the rights of the patient to be fully informed about the procedure, encouraging them to do their own research on the facial toning procedure, as well as to ask the staff questions about what to expect. It also describes the procedure, what will happen, what the benefits are, and what to expect following the procedure. It also recommends how many treatments a patient should have and over what period of time, and also advises to follow up with monthly facials for optimal results.

There is a section where the patient can check off any health conditions that they have had or are currently experiencing - conditions such as cancer, heart problems, thyroid issues, diabetes etc. The form also states the limitations under which the procedure can't be performed - cancer, heart problems, or contra-indications such as epilepsy, seizures, or a variety of skin conditions and if taking drugs for certain skin conditions (Retin A, Accutane etc)

The final section of the form contains text for procedure authorization to perform the microcurrent facial toning and a waiver ensuring that the patient understands the risks of the treatment, and that they assume the risk and full responsibility for injuries, losses, damages etc which might occur during or after the procedure. There are finally sections for signatures of the patient, guardian, and witness. As with all GoCanvas forms, all sections and texts are fully customizable.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Authorization and Consent For Microcurrent Facial Toning (Canada) Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    {Insert company name/address}

  • Ico statictext

    AUTHORIZATION AND CONSENT FOR MICROCURRENT FACIAL TONING

  • Ico statictext

    UNDERSTANDING BY SIGNING YOUR NAME ON THE FINAL SCREEN.

  • Ico statictext

    TO THE PATIENT.

  • Ico statictext

    PROCEDURE.

  • Ico statictext

    HOW TO ACHIEVE OPTIMAL RESULTS: For the best results, we recommend a series of 10 microcurrent tr...

  • Ico textbox

    Name

  • Ico date

    Date

  • Ico statictext

  • Ico statictext

    Please check any health conditions which you have had or are now experiencing:

  • Ico checkbox

    Cancer

  • Ico checkbox

    Heart Problems

  • Ico checkbox

    Seizures

  • Ico checkbox

    Epilepsy

  • Ico checkbox

    Thyroid Disorder

  • Ico checkbox

    High/Low Blood Pressure

  • Ico checkbox

    Hepatitis

  • Ico checkbox

    Diabetes

  • Ico checkbox

    Thrombosis/Phlebitis

  • Ico checkbox

    Hypoglycemia

  • Ico checkbox

    Muscular Conditions Recent Pregnancy

  • Ico checkbox

    Lack of Normal Skin Sensation

  • Ico checkbox

    Metal Implants, Screws

  • Ico checkbox

    Multiple Sclerosis

  • Ico checkbox

    Recent Illness

  • Ico checkbox

    Pregnancy

  • Ico checkbox

    Botox®

  • Ico checkbox

    Recent Dermal Fillers

  • ...and More!

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